Vascular surgery

Dr. Popa Radu

1st course
 Vascular injuries
The progress in the techniques of resuscitation and
vascular repair have resulted in the progressive
reduction in the amputation rate in major limb injuries.
While the amputation rate was
– nearly 80% in the battle injuries to limbs in World War I
(1914/18)
– it fell to 50% in the World War II (1939/44) and
– it was further reduced to around 10% in the more recent wars
If not recognized and treated rapidly, injuries to major
arteries, veins, and nerves may have disastrous
consequences resulting in the loss of life and limb.
Incidence - between 0,07 and 2,5% from total of trauma
In orthopedic field – vascular trauma exceed
5% (Candea ) to 6,5% (Bishara).
years of productive life lost (YPLL)if
the patient would survive
For each traumatic death there are, on
average :
36 YPLL
compared with
16 for cancer and
12 for cardiovascular diseases.
 CLASSIFICATION

The following are the types of injuries to arteries.

Open injuries
a) Division or laceration of the artery
b) Traumatic false aneurysm (Pulsating
Haematoma)
c) Arterio-Venous Fistula
Closed injuries
a) External compression
b) Arterial spasm
c) Thrombosis following intimal tears
Closed injuries are the commonest cause of acute
traumatic ischaemia in a limb.
 ETIOLOGY – Closed and open injuries

The cause of vascular obstruction could be :

c) outside the wall of the vessel
d) in the wall
e) inside the lumen of the vessel
External compression of the vessels can be caused by
– a) tight plaster, tight bandages, etc.,
– b) subfascial haematoma in places like cubital fossa, popliteal fossa,
– c) increasing traumatic edema of the muscles in the forearm or in calf,
– d) Direct pressure by the fractured bone end.
Internal obstruction may follow injury to the arterial wall (stab
wound or closed injury) , arterial spasm, thrombosis or embolism
 SUSPICION OF INJURY

CAUSES
Penetrating(open) wounds
– Gunshot, stab,
– IV drug abuse
Blunt trauma (closed)
– Joint displacement - Adjacent to major artery
– Bone fracture
– Contusion
Invasive procedures
– Arteriography
– Cardiac catheterization
– Balloon angioplasty
– Hernia repair
– Saphenectomy
 HARD SIGNS OF ARTERIAL INJURY

Immediate surgery
– External arterial bleeding- Hemorage
– Rapidly expanding hematoma
– Palpable thrill, audible bruit
– Obvious arterial occlusion (pulseless, pallor,
paresthesia, pain, paralysis(especially after
reduction or dislocation or realignment of fracture).
SOFT SIGNS OF ARTERIAL INJURY

– • History of arterial bleeding at the scene

– • Proximity of penetrating wound or blunt
trauma to major artery
– • Diminished unilateral distal pulse
– • Small nonpulsatile hematoma
– • Neurologic deficit
– • Abnormal flow-velocity waveform on
Doppler ultrasound!!!!!!!!!!!!!
Consider arteriography
Initial Management of Potential Vascular
Injuries

Peripheral vascular injuries do not compete with those

that are immediately life threatening, but take priority
over most other injuries.
Once the initial resuscitation is under way, bleeding
controlled, and the airway secure, the extent and nature
of the vascular injuries are fully assessed.
Vessel wounds causing distal ischemia require urgent
operative restoration of flow; the repair is delayed only
for hemodynamic stabilization and treatment of other life-
threatening problems.
Additional resuscitation or further diagnostic evaluation
(such as arteriography) can be accomplished in the
operating room, if indicated.
 Emergency
The first 6 hours !!!!!!!!!!!!
 Prehospital Care:

Stabilize the extremity in the anatomic

position.
Control hemorrhage with direct pressure.
Apply a tourniquet proximal to the injury if
direct pressure is not effective in
controlling hemorrhage.
Emergency Department Care
Immediately reduce displaced or angulated fractures if any evidence
or suspicion of vascular compromise exists. Promptly reduce
dislocations of the elbow and knee to prevent further injury to
neurovascular structures.
External hemorrhage usually can be controlled with direct pressure,
but a blood pressure cuff or tourniquets should be applied
proximally to the injury if compression fails or is not possible.
Once the patient has been stabilized, identify peripheral vascular
injuries and restore normal circulation as rapidly as possible.
Do not apply clamps or hemostats to vascular structures, since this
may make definitive repair more difficult and damage surrounding
tissues.
 Arteriography
and Duplex scan
Arteriography is the single most useful
diagnostic procedure for detecting an
arterial injury.
Clinical studies have supported its
accuracy in the management of such
trauma, but the procedure has only
recently been accepted as a means of
detecting arterial wound.
 REASONS FOR DIAGNOSTIC STUDIES

• Prevent unnecessary operation!!!!!!!!!!!!

• Document presence of surgical lesion
• Localize surgical lesion to plan operative approach

ARTERIOGRAPHY
– • Can be performed by radiologist using intraarterial
digital subtraction angiography or CT
– • Can be performed by surgeon in emergency
– room or operating room
ARTERIAL LESIONS DOCUMENTED BY
ARTERIOGRAPHY
– Contusion
– Partial transection
– Arteriovenous fistula
– Complete Transection
 DUPLEX SCAN

Definition:
Real-time B-mode –anatomic image
combined with
A pulsed-wave Doppler image (flow
determination).

– Duplex scan should be performed by a

competent vascular technologist or surgeon
 Duplex: combination between

(1) Doppler (2) echografie

Anatomy of the wall :

Diameter , ulcerated plaque
Signal spectrum ,transection of artery .
 Diagnostic
algorithm
for extremity arterial
trauma. ABI, ankle-
brachial index.
 FINE POINTS IN PERIPHERAL VASCULAR
REPAIR

• Small vascular clamps or vessel loops

• Pass balloon catheters into artery proximal
and distal to repair
• “Regional” heparin (50 units/mL), 10–15 mL
into artery proximal and distal to repair
• Completion arteriography

• Fasciotomy for compartment pressure >30–35

Hg (suspect compartment syndrome if prolonged
period of shock or arterial occlusion, combined
Arterio-venous injuries, need for arterial or
venous ligation, or massive crush or swelling
is present)
 OPTIONS FOR PERIPHERAL VASCULAR
REPAIR

• Lateral arteriorrhaphy or venorrhaphy

• Patch angioplasty
• Resection with end-to-end anastomosis
• Resection with interposition graft
• Bypass graft
• Extraanatomic bypass
• Ligation
Phalse aneurysm+/-
Elbow joint luxation
TREATAMENT
Stab Wound
Vein interposition
Trauma of aortic arch
enlarged mediastinum
Rupture of the aorta
– Aortography-
 Hemothorax
– laceration of the thoracic internal artery -
Aorto-caval fistulae
Figure 72-6
Postoperative CT
scan of a patient with
a gunshot wound
shows an aortocaval
fistula (circle).
OPERATIVE MANAGEMENT:
GENERAL PRINCIPLES
Figure 72-7 Five-
year-old child with
severe pelvic fracture
and absent right
femoral pulse.
Angiography shows a
complete occlusion of
the right common iliac
artery (arrow).
CT of a traffic
accident victim shows
a large pelvic
hematoma (circle)
due to injury of the
right common iliac
artery.
CT scan with
intravenous contrast
material following a
fall from a significant
height shows poor
contrast uptake of the
right kidney due to an
occlusion of the renal
artery (circle).
Postoperative CT
scan of a patient with
a gunshot wound
shows an abdominal
aortic false aneurysm
(circle).
Popliteal artery shotgun injury
with a small false aneurysm
(arrow), which was managed
nonoperatively
The same case ;intraop vue ;ligation of
caval vein preventing exitus
Carotis wound repair with
a patch
Endovascular
Management
A large peroneal artery
false aneurysm was
successfully treated by
coil embolization .

Currently available coils

are made from stainless
steel and are wool or
Dacron tufted

Another endovascular
approach to extremity
injuries uses stent-graft
technology
ACUTE ISCHEMIA
 ETIOLOGY

1. Emboli 4. Dissection
2. Thrombosis spontan
atheromatose iatrogen
post surgery 5. Compression
hypovolemie DVT
thombocytemie post surgery
maligne tumor… 6. Trauma
3. Spasm spontan
ERGOTAMINE iatrogen
adrenergical infusion
dopamine...
 ARTERIAL EMBOLI

1. Cardiac (80% to 90%)

2. Aneurysma

3. Paradoxal emboli
Ateroembolism
ACUTE ISCHEMIA -SIMPTOMS

6’s P PRATT
1954

1. Pain

2. Paleness(palor)

3. Paresthesia

4. Pulselessness

5. Paralysis

6. Prostration
Society for Vascular Surgery/International Society for Cardiovascular
Surgery (SVS/ISCVS) committee on reporting standards

– Viable: not immediately threatened.

There is no ischemic pain,
no neurologic deficit,
adequate skin capillary circulation, and
clearly audible Doppler pulsatile flow signal in pedal arteries (ankle
pressure > 30 mm Hg).

–Threatened viability: indicates a state of

reversible ischemia provided arterial obstruction is promptly relieved.
Ischemic pain or
mild and incomplete neurologic deficit is present.
Pulsatile flow in pedal arteries is not audible with Doppler, but venous
signals are demonstrable.
Society for Vascular Surgery/International Society for Cardiovascular
Surgery (SVS/ISCVS) committee on reporting standards

3. Irreversible ischemic change:

profound sensory loss and
muscle paralysis,
absent capillary skin flow,
muscle rigor, and
skin marbling are characteristic.
Neither arterial nor venous flow is audible;
major amputation is required, regardless of
therapy.
Dependent edema
and ischemic
blisters( vezicule)
seen in a patient
with acute
Irreversible limb
ischemia.
 Acute ischemia -medical treatment

1. Heparin I.V .
2. Analgetics (even morphine
3. Quiqly transport hospital
Embolic occlusion of the
axillary artery. Note the
typical site of embolic
occlusion at branch
points and the "meniscus"
(arrow) seen with the
embolic occlusion on the
diagnostic angiogram.
Acute Ischemia of popliteal
artery
Acute in-situ thrombotic
occlusion of the popliteal
artery. Note the absence
of significant collateral
channels.
The patient had no
Doppler pedal signals.
An embolus is lodged at the
bifurcation of the profunda
femoris artery and the
superficial femoral artery.
The diameter of the
common femoral artery is
large enough to allow the
intravascular debris to
travel through it, but the
individual diameters of the
profunda femoris artery and
the superficial femoral
arteries are too small.
This photograph
emphasizes the finding that
most emboli lodge at the
branch point.
Embolectomy Fogarty probe
Embolectomie cu sonda Fogarty
 Pharmacologic thrombolysis

The most commonly used plasminogen

activators are :
– recombinant tissue-plasminogen activator (rt-
PA),
– reteplase,
– urokinase,
– prourokinase, and
– streptokinase
Locale thrombolyse
Percutaneous mechanical thrombectomy

Relatively recently, percutaneous devices have been

employed in an effort to rapidly extract intra-arterial
thrombus and restore arterial flow to the extremity..
The potential benefits of mechanical thrombectomy
devices include the ability to establish more rapid
reperfusion of the ischemic extremity, shorten the
duration and lessen the dose of pharmacologic
thrombolysis by debulking the thrombus and, in some
cases, avoid the use of thrombolytic administration
altogether when contraindications to thrombolysis are
present.
 AngioJet
System
AngioJet pump
drive, catheter,
and evacuation
setup.
 AngioJet system
The AngioJet system consists of three major components: the catheter, the pump set,
and the drive unit
The pump set and the drive unit are responsible for producing a controlled high-
velocity saline jet (350 to 450 km/hr) that is redirected at the tip of a dual-lumen
catheter back into the effluent lumen of the catheter
The inflow lumen is a low-profile stainless-steel tube that forms a transverse loop at
the distal end of the catheter and has multiple small orifices (25 to 50 μm diameter
each) directed retrograde toward the inflow lumen.
The high velocity of the saline jets produces an area of extremely low pressure
(Venturi effect) that is exposed to the intra-arterial lumen at the tip of the
catheter. Thrombus surrounding the catheter tip is fragmented (99.8% < 100 μm) and
rapidly evacuated through the effluent lumen.

Since it is concerned with thrombus, the actual mechanical force of the saline does
not produce removal, but by an indirectly created negative pressure zone (-760 mm
Hg), luminal endothelial damage is minimal.
A, Acute in-situ thrombotic
occlusion of the popliteal artery.

B, Following an 8-hour infusion of

urokinase followed by AngioJet
thrombectomy, the patient had
complete resolution of the
thrombotic occlusion
•Reperfusion
syndrome
•Compartment
syndrome
•Fasciotomy “
•As pointed out by Haimovici in 1960,
however, reperfusion of an entire
severely ischemic limb often results
in a systemic inflammatory response of
such magnitude that it may be lethal
Fasciotomy
 Acute trombosis
Due to the chronic arterial disease
– Arteriography is important
 Differentiation of Embolism and Thrombosis

FACTOR EMBOLISM THROMBOSIS

Identifiable source Frequently detected None

Claudication Rare Frequent

Physical findings Proximal and contralateral Ipsilateral and contralateral

pulses normal evidence of peripheral
vascular disease

Angiography Minimal atherosclerosis, Diffuse atherosclerotic

sharp cutoff, few disease, tapered and
collaterals, multiple irregular cutoff, well-
occlusions developed collateral
circulation
 Blue toe syndrome
In its classic presentation, the blue toe syndrome manifests as the
sudden appearance of a cool, cyanotic, and painful toe on a foot
with palpable distal pulses.
Discoloration may also be seen on the sole of the foot. The
discoloration may be patchy, and comparison of the two feet shows
that the distribution is not symmetrical.
These lesions may progress to ulceration, necrosis, and gangrene.
Accessory lesions may be present on the lateral and posterior
aspects of the heels and may later develop into linear fissures with
skin edge gangrene and a dark, necrotic base.
T.E.E.
Transesophageal
echocardiogram
demonstrating mobile (seen on
real-time imaging) protruding
aortic atheromas located in the
aortic arch (A) and descending
thoracic aorta
(B). This patient has had
multiple strokes due to
atheromatous embolization
from the ascending aorta and
aortic arch.
 Acute dissection
Iatrogenic – surgical maneuvers,
investigations
Spontaneus ; dissection of anevrysma
 Treatment of acute disection
Interposition with syntetic graft - Op
Bentall-
Partial resection –by pass
Fenestration
Fenestrare spontana
Fenestration
…….. Bij zeer distale en diffuse embolen
Fiziopatologia ischemiei acute

Rezistenţa la ischemie a unei extremităţi este

greu de apreciat. Poate fi mai degrabă apreciată
rezistenţa unei anumite populaţii celulare
Se admite că la nivelul muşchilor scheletici şi al
nervilor periferici apar leziuni ischemice
ireversibile după 4-6 ore de ischemie severă.
 Ischemia ireversibila
În ischemia depăşită apare pigmentarea fixă –
staza -(ce nu dispare la presiune) ce are o
semnificaţie similară lividităţilor şi care indică
stadiul de ireversibilitate
Examinarea maselor musculare este de o
importanţă deosebită. Pe măsură ce ischemia
avansează se produce umflarea celulelor şi
apare edemul ischemic. Astfel, muşchii îşi pierd
consistenţa lor obişnuită şi devin induraţi, fermi,
fără elasticitate. Această modificare a
consistenţei semnifică apariţia necrozei
musculare şi are un prognostic prost.
Manifestari clinice si diagnostic

Diagnosticul precoce este esenţial!!!!!!

Embolii se opresc cu predilecţie in zonele de bifurcaţie a arterelor.
Are loc încetinirea marcată a curgerii sângelui în teritoriul din aval
de ocluzie, fenomen care favorizează propagarea distală a
trombozei intravasculare.
Dacă nu preexistă o circulaţie colaterală bine dezvoltată, necroza
musculară şi modificările ireversibile apar după 4-6 ore de la debut.
Cu cât tratamentul este instituit mai precoce cu atăt recuperarea
este mai bună.
 Ischemia acuta tratament
Extremitatea ischemică trebuie ferită de căldură.
Căldura creşte rata metabolică celulară
agravând leziunile celulare. În acelaşi timp,
căldura aplicată încălzeşte mai ales straturile
superficiale şi produce vasodilataţie la nivelul
acestora agravând şi mai mult ischemia
straturilor profunde
prin efect de furt sangvin şi deschiderea
şunturilor arterio-venoase.
 Tratament chirurgical
Multe dintre episoadele de ischemie acută
periferică pot fi rezolvate
eficient sub anestezie locală.

Anestezia generală este necesară în cazul

în care se are în vedere o reconstrucţie
vasculară de amploare(by pass –
tromboza acuta )
 ETIOLOGIE -Tromboza acuta

1. Embolia 4. Disectia
2. Tromboza spontana
ateromatoza iatrogena
postoperatorie 5. Compresie
hypovolemie TVP
trombocitoza post chirurgie
tumori maligne 6. Trauma
3. Spasmul contuzii si plagi
ERGOTAMINE iatrogen
adrenergica
dopamine...
 Tromboza acuta
Arteriopatie periferica cronica
– Atac acut – subacut
– Durere moderata spre severa
– Picior(mina ) palida ,rece ,vene colabate
– Puls absent
– Arteriografia este suverana
Tratamentul trombozei acute
Diferentiat
RAR -embolectomie
FRECVENT –TEHNICI DE
DEZOBSTRUCTIE SAU BY PASS
Tromboliza locala
 Disectia acuta
Iatrogena –manevre chirurgicale,
investigatii
Spontana ; anevrisme disecante de aorta
–coloana de singe intre medie si intima cu
decolare si disectie pina la ostium(trunchi
celiac,AMS….)
Tratament disectiei cu ischemie
acuta
Inlocuire –Interpozitie de grefon sintetic -
Op Bentall-
Rezectie partiala , anevrismectomie si by
pass
Fenestrare
 Tasc
In contrast to the early stages of PAD, in
which compromised skeletal muscle blood
flow causes intermittent claudication, rest
pain and trophic changes associated with
CLI are predominantly attributable to a
critical reduction in skin microcirculation.
FIGURE 2. Digital subtraction pelvic arteriogram. (Left) There is a severe stenosis of the right common iliac
artery (arrow). (Center) Image hold. Deployment of a Palmaz stent mounted on an angioplasty balloon,
seen in its fully expanded state. (Right) Magnification digital subtraction arteriogram center at the aortic

bifurcation. Following stenting, the right common iliac artery is widely patent.